24D-311 VDAC
,,,,,,,.
TRAVELERS J WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (7PJUB- 0545N13 -1 -09
RENEWAL OF (7PJUB- 7757B37 -1 -08)
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
1 NCCI CO CODE: 13579
INSURED: PRODUCER:
DELONG CONSTRUCTION LLC WHALEN INSURANCE AGENCY
76 BANCROFT ROAD 71 KING STREET*
NORTHAMPTON MA 01060 PO BOX 478
NORTHAMPTON MA 01061 -0000
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period Is tram 05 -26 -09 to 05 -28 -10 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
of .Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
a = C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
0
NININIMiew
D. This policy includes these endorsements and schedules:
o. r SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05 -12 -09 DR ST ASSIGN: MA
OFFICE: DIRECT ASSIGNMENT 701
PRODUCER: WHALEN INSURANCE AGENCY 28LKF
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two -year period shall not be considered a
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations The inspection process reauires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill)
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
—
—pe its- in- conjunction_to -the_ aitissued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Address of work
location
1
The Commonwealth of Massachusetts
• , Department of Industrial Accidents
Office of Investig,ations
° Ifa j =
600 Washington Street
• =' = Boston, MA 02111
www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individ / co-4 , C< (.
Address: 7 Cfre j • , •
City /State/Zip: / o ?'`/ ' . o' ° -go Phone. #: c / a -ire 7 — o 4' 37
Are you an employer? Check the appropriate box: Type of project (required):.
1.0 I am a employer with 4. (g I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub - contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodelling
ship and have no P-np10 }gees These sub - contractors have. .8. 0 Demolition
working for me in any capacity. aci tY employees and have workers'
9. 0 Building addition
No workers' comp. insurance _ comp. msunance.$
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am -a- homeowner - -dein alloffic have lxercised it 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.g Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. No workers' 13.0 Other
comp. insurance required.].
*Any applicant that checks box #1= must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name: Tic 4 YG e t`'s s t iO .
Policy # or Self-ins. Lic. #: ' 7 'Pi' v 3 7 7 J 7 33 7 " "- CS" Expiration Date: S1 %O
Job Site Address: 7FW s34,rciacici- z 7 City /State/Zip:* A6 ` 7
Attach a copy of the workers' compensation policy declaration page (showing the policy nnmber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against die violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and peno/t►Ps of perjury that the information provided abov-e_ittrue and_correc . __ _ _
Signature: at 2. / /w 0
Phone #: ( - 68 ? °1
Official use only. Do not write in thin area; b be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical I s • ector 5. Plumbin! Ins • ector
6.Other
Contact Person: Phone #:
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of license Holder : - —W/Y/ k AA C3 — 925
License Number
762 & /(,3'Cf R "l 4A•rf70 .v1 A' pat , ,,... ) 3/25/20A -I
Address Expiration Date
Signature Telephone
9:<; Registered, Home- lmProvement..CoritraCtiii ,.a, ,e -U ., Kw, .. ,. ik , Not Applicable ❑
D& _ )t,e .J , Ccc_ I S/ 6q
Company Name Registration Number
7G & - -6,,(1 127f) r. 61/S /2010
Address Expiration Date
J./JCiettrr7707h/, .€44 0 /Ob.3 Telephone / 13'St77- 37
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes [,il' No ❑
The_current_exemption for "homeowners "was extended to include Owner- occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
o amp on • r■ finances; a e -- s-•General Laws -- Annotated.
Homeowner Signature
• J
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) D Roofing Ea
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [C] Siding [0] Other [0]
Brief Description pf Proposed
Work: ,c12/ p /Z ) 5 H/JG -tt ;2e a4cL " /6t/ / c ' O O Cii/G
Alteration of existing bedroom Yes No Adding new bedroom Yes X No
Attached Narrative .Renovating unfinished basement Yes )( No
Plans Attached Roll - Sheet
6a, 1 tetnr;;ealt.oiaci(iiocf�tisr uslp cainiefie tt €citTTo�riri:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta!:- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
EGA ZA - f' 33e1" 4-7) , as Owner of the subject
property
hereby authorize Ed G E'/N/ v
to act on my behalf, in all matters relative rk a orized y t ' building permit application.
6 `J 2 / / ii o
Signature of Owner Date
1 , /
, as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
64 Z.,,✓.f /H�z.,
Print Name
Signature ofZwnen'Agent Date
1
A
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size r _ - .._. ____
Frontage € -- < <� m__
Setbacks Front i i ; i I
Side L €._.., , R: L: ` R:?.L, i c.....- t
Rear L _._. L -
Building Height
Bldg. Square Footage p _.Y 1 1 1 I I
Open Space Footage _. % i
(Lot area minus bldg & paved „„�, ! __„__..,
parking)
# of Parking Spaces ? - -• -- --
______
Fill: 1 w_,.0 __ a._
(volume & Location),
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book § ! Page _ t and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: }
D re [here any proposed c ianges to or as loons o signs in enied for the property ? YES 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t
s i'` ,fir . D om. '" 9 w t t � ` E:.. :
City of Northampton
Building Department
•10 212 Main Street - - ,
Room 100 a
,v Northampton, MA 01060 H q
phone 413 - 587 -1240 Fax 413 - 587 -1272 ° . 11
� H *-t' e 7 . ; $ Y f
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
76 3 120 / i Map Lot Unit
f /Ole3l*Y 4 Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT I _
1
2.1 Owner of Record:
-- - --41 i vpv ;42 , 1 34.4- 2 47 l .
Name (Print) �� Current Mailing Address:
Telephone ,46,- 6475 - 36462.
Signature
2.2 Authorized Agent:
Fd Itira v 7 6 g4nit'2v , e - % lc
Name (Print) Current Mailing Address: ,,// �/��
.7-
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant _
1. Building .TIDO 4 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
"` Construction from (6)
3. Plumbing i7 ^ Building Permit Fee
4. Mechanical (HVAC) 0
5. Fire Protection —' C
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 44 1 l A J 00
This Section For Official Use Only
Permit Number:
Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
76 BANCROFT RD BP- 2010 -0740
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map;Block: 24D - 311 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0740
Project # JS- 2010- 001096
Est. Cost: $7000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED LENNIHAN 042506
Lot Size(sq. ft.): 17728.92 Owner: LENNIHAN EDMUND D & JENNIFER D ADDAS
Zoning: URAU100)/ Applicant: ED LENNIHAN
AT: 76 BANCROFT RD
Applicant Address: Phone: Insurance:
76 Bancroft Road 587 -0437
NorthamptonMA01060 ISSUED ON:2/18/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 2/18/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo